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Please read my post carefully. I said that there are pts that can breath fine even when they have some fade. I didn't say that I didn't reverse pts with some fade.
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Intraop analgesics
Started by GassmanMD
I read, but disagreed
That's your prerogative.
To clarify, If my pt has fade then I reverse.
To clarify, If my pt has fade then I reverse.
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deleted171991
If the patient is weak, s/he will definitely not have enough force to retch and throw up. So, from PONV standpoint, not giving neostigmine is a win-win situation. 😀
In regards to intra-operative analgesia, shouldn't we be worried about central and peripheral sensitization if we do not provide adequate analgesia? Is blocking the hemodynamic effects of sympathetic outflow secondary to pain enough to prevent this? I'd like to see data on multimodal anesthesia (i.e. targeting all the receptors in the pathway) during the case and its effects on acute post operative pain and chronic post operative pain.
Are saying that the pts might have chronic pain if we don't treat intraoperative pain?
Pain is a very difficult thing. There are many theories but nothing truly definitive. Two people may experience the same pain in completely different ways. Narcotics can help and they can hurt. Multimodal can work well or not at all. The same injury can progress to chronic pain in one person and not in another.
My understanding of central sensitization or otherwise known as centralization of pain is that it takes longer than any surgical case. Usually, weeks to months.
Peripheral sensitization however, I don't know what you mean here. Perpheral nociceptors are what are being stimulated during surgery. But this doesn't cause chronic pain. Peripheral pain is what we are treating during surgery. When the stimulus stops the pain begins to wane. It is not until the pain becomes centralized in the Dorsal Root Ganglion and beyond that the pain becomes chronic. At least this is how I remember it. Maybe someone can correct me here.
Well, its well accepted that uncontrolled post operative pain can put patients at risk for chronic pain for certain procedures. I was just theorizing that the process starts even earlier...
But like you said, happens in some, and not in others. Regardless of sensitization, maybe some individuals are predisposed to be sensitive to pain from nerves which are cut, which is perhaps different than the nociception from the inflammation associated with surgery which is temporary.
But like you said, happens in some, and not in others. Regardless of sensitization, maybe some individuals are predisposed to be sensitive to pain from nerves which are cut, which is perhaps different than the nociception from the inflammation associated with surgery which is temporary.
You have valid points. However, the answer is not at the opioid receptor. In fact, opioids may make it worse but we just don't know. Micro glia - huge players in chronic centralized pain - have opioid receptors that act in both nerve inhibition and hypersensitization. Which one will predominate in any given patient is anyone's guess. Better to use multimodal with other stuff.
For those that use them, what is your dose of Mg/lidocaine/esmolol? When are you giving them, how fast are you infusing them? If you give ketamine, is it redundant to also give Mg?
I give 2 g mag sulfate intraop while asleep. Pharmacy sends it in a little bag. However, the other day I got called to the pacu for a patient in pain and gave it. Pacu nurses were perplexed at first. Upon seeing the results though they were stunned and kept asking how it worked. As an aside, does anyone have any proven reason or experience that might argue against giving it to ALL of our major spine cases? We are a nationwide spine center that does some gnarly cases and many patients are opiod tolerant.
I just add 2 g to the IV bag after induction and let it drip in over a nonspecific while. I don't see a reason to not also use ketamine.
When you give Mg to awake pts as in the pacu be aware, they will get a warm feeling overall. Think this is part of what makes them feel better as long as you tell them about.
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deleted171991
Which reminds me (off-topic) to never bolus decadron in awake patients. 😀
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deleted171991
Only in females, and I only made the mistake a couple of times but, boy, was it wild!
It happens in males, too. I remember giving it just prior to induction to one young man, and his last words before losing consciousness were "Oh my God, why is my crotch burning?!" Thankfully, he had no memory of this afterwards.
Lidocaine dosing -
Need loading dose. I mix my propofol with 2cc of lidocaine - unless I am going to use a lidocaine infusion. In that case, on induction, give 1mg/kg lidocaine.
Then dose as below - run as long as you want (post extubation - in the pacu, on the floor, etc)
4 methods
1. 1.5-2mg/kg/hr
2. 30mcg/kg/min
3. <80kg = 2mg/min, >80kg = 3mg/min
4. My favorite - if using the premixed lidocaine bag (red letters, 8mg/ml), take the weight in kg x .225 = ml/hr
In the end, just run the pump from 15 ml/hr to 24 ml/hr based on how big they are.
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I choose 1 infusion adjuvant for chronic pain, ie not ketamine and lido, or mag and ketamine, just choose one. You just cant cover ALL the nociceptors that are being discovered/researched now. So just pick one which has been proven efficacious and will help your anesthetic go smoothly (not endanger it). In my experience, these drugs mentioned already have a nasty side effect profile, with little BANG for the risk (except ketamine)
My favorite analgesic adjuvant infusion is: dexmedetomidine. Use only for cases more than one hour. Start at 0.8 mcg/kg/hr and let it run until the heart rate starts to drop ( or about 30 minutes ) then turn it down to 0.4. Give glyco as needed to increase heart rate. You will then have a dry, stoned, breathing patient in the PACU who is cooperative and not causing problems for the next few hours. (not good for crisp wake-ups)
My favorite analgesic adjuvant infusion is: dexmedetomidine. Use only for cases more than one hour. Start at 0.8 mcg/kg/hr and let it run until the heart rate starts to drop ( or about 30 minutes ) then turn it down to 0.4. Give glyco as needed to increase heart rate. You will then have a dry, stoned, breathing patient in the PACU who is cooperative and not causing problems for the next few hours. (not good for crisp wake-ups)
This is interesting. What nasty side effects have you seen with lidocaine infusions? If you indeed have seen some, you should report them since I can't find a single report of ANYTHING bad happening with the studies of lidocaine infusions.
Most studies show a very worth-while BANG, with very very little risk. The only caveate being in orthopedic same day surgery - benefit has not been proven. I still use it though.
Epidural man if you don't mind sharing some high quality articles on lido infusion please do.
I did some for a while for back cases then dropped them because clinically i wasn't seeing much effect.
For abdominal cases i don't see much use since i'm doing TAPs
I did some for a while for back cases then dropped them because clinically i wasn't seeing much effect.
For abdominal cases i don't see much use since i'm doing TAPs
Here is what I have in my articles folder. I haven't looked at google.scholar recently.
Some more...
Here are some spine articles.
And even more....
It doesn't seem to work in breast cases.
Quickly looked ar the spine data and as i said it doesn't seem to be significant clinically.
For abdominal cases i highly doubt the efficacy if you are doing TAP blocks.
The Belgian study on lap colectomy has a 2 day average stay in the lido group ( for an academic hospital!!) gaining 1 day over no lido? Highly suspicious...
For abdominal cases i highly doubt the efficacy if you are doing TAP blocks.
The Belgian study on lap colectomy has a 2 day average stay in the lido group ( for an academic hospital!!) gaining 1 day over no lido? Highly suspicious...
dhb,
Why not do both? lido infusion and then a TAP?
What is the downside to a lido infusion?
Why not do both? lido infusion and then a TAP?
What is the downside to a lido infusion?
How much local you plan on putting in that patient?
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We're in the middle of a big push and huge learning curve with all the multi-modal techniques and drugs. With more than 200 anesthesiologists, AAs and CRNAs, some old, some new, some progressive, and some more set in their ways, and spread out over multiple hospitals and ASCs, it's quite a trick to move everyone in this direction.
Besides the various blocks, which is a whole different topic - we are doing a lot of bigger (and some smaller) spine and colon cases with both ketamine and lidocaine infusions and using minimal, if any, narcotics. We use IV acetaminophen on just about everything (it's cheap, it works), ketorolac on those patients where the surgeons don't freak out about it, and dexamethasone. Various pre-meds include pregabalin or gabapentin. Haven't tried Mg yet, but considering how well some of these other "new" drugs have worked, I'm certainly willing to try. I'm one of the old dogs, but some of these new tricks are pretty impressive if you give them a shot. Multilevel all-day spine fusions with no narcotics? Whoulda thunk?
Besides the various blocks, which is a whole different topic - we are doing a lot of bigger (and some smaller) spine and colon cases with both ketamine and lidocaine infusions and using minimal, if any, narcotics. We use IV acetaminophen on just about everything (it's cheap, it works), ketorolac on those patients where the surgeons don't freak out about it, and dexamethasone. Various pre-meds include pregabalin or gabapentin. Haven't tried Mg yet, but considering how well some of these other "new" drugs have worked, I'm certainly willing to try. I'm one of the old dogs, but some of these new tricks are pretty impressive if you give them a shot. Multilevel all-day spine fusions with no narcotics? Whoulda thunk?
downside of lido infusion:
local anesthetic toxicity/limitations if surgeon or you is doing a block (probably a good idea in the population needing a lido infusion)
conduction abnormalities
it doesnt work very well (same experience as another poster who said no effect)
you shouldnt have to look at studies to see that outcomes with lido vs dex are like saline vs opiate. really your in pain? you shouldnt be according to this study.. run a little dex and the difference will be obvious to you and all who take care of the patient.
1. Conduction abnormalities? Haven't seen them. Very low incidence in the studies - usually comparable to control group if any were seen so unable to say was a lidocaine phenomenon.
2. Doesn't work well? For what? Please be specific. Doesn't work well in abdominal cases to return bowel function? Decrease discharge? Decrease opioid consumption? If your experience is indeed that it doesn't work for anything, you absolutely should prove it. Your wonderful experience seem to go against what many others seem to be finding.
3. dex? what are you talking about? Dextromethorphan? Dexamethasone? dexmedetomidine? Dextrose? And what differences? Pain scores? Time to pacu discharge?
And by the way, when do you see arguing that lidocaine is better than all other analgesics?
Finally, what do you mean "you shoulnd't be according to this study...run a little dex and the difference will be obvious to you ..." I'm not sure of your point. Are you suggesting that I shouldn't be a pain physician, or I am not clever enough to be a pain physician because I haven't run a head to head trial between dex and lidocaine? Or perhaps you mean if i did the study, and wasn't astute enough to see the obvious difference, then I am not worth a damn and shouldn't call myself a pain physician? Or are you saying that I am such an imbecile that I would have never even considered a little dex? I'm just very confused by that statement.
Not to mention expensive; there are cheaper ways to smooth your wake ups
Was that before they quadrupled the price of the IV acetaminophen about 3 months ago? It's now about $48 a vial (I think) for acquisition cost and far pricier to the patient unless they are paying a bundled fee. But you know what isn't expensive? PO Tylenol. And it is equally efficacious.
We get a price break so it's a good bit less than that. In our experience, it works significantly better than PO.
Nurses like to give it because it kicks in fast. There is no evidence that it is more efficacious than good old fashioned PO when given ahead of time. The PO also costs a lot less.
We have both. I've used both. I give PO tylenol preop with a sip of water and see zero difference in the PACU compared to IV.
What's to gain if pain is well controlled? i always try to do the block before surgery starts
never meant you any offense. what i am trying to say is dont keep doing the same thing over and over because a study says it might have a little benefit. literature behind lots of the pain practices we pain doctors do is weak to say the least for a variety of reasons. try a lot of different intra-op infusions, like ketamine, dexmedetomidine, remifentanil, and see which you like for each situation. in my experience, lidocaine did nothing, dexmedetomidine has been the bestby far in terms of obvious observable outcomes with my own eyes. if you think lido infusions really make that much of a difference then thats great
Non opioid pain control is the goal and all benefits derive from it. Now if you think it's the lido by itself that's responsible for the quick return of bowel function, earlier ambulation, earlier discharge etc... it's more a wish than a reality.
